Fighting, battling, and beating: combat metaphors in medicine are just wrong

Are you “battling” heart disease”? Have you “beaten” cancer? Are you “fighting” a chronic illness? These wartime references are metaphors as described byDr. Jack Coulehan, a physician, an award-winning poet, and editor of the 5th edition of The Medical Interview: Mastering Skills for Clinical Practice, a best-selling textbook on the doctor-patient relationship.(1) Dr. C explains that there are several basic metaphors used in medicine that to a large extent generate the vocabulary of doctor-patient communication – but can also unintentionally objectify and dehumanize the patient.

Here are three of the most prominent metaphors you’re likely to encounter in health care:

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Parental (paternalistic) metaphor

Disease is a threat or danger (“She’s too sick to know the truth”)

Physician is a loving parent/ patient is a child (“We don’t want him to lose hope”)

Engineering metaphor

Disease is malfunction (“He’s in for a tune-up”)

Physician is an engineer or technician (“Something’s wrong, doc – you fix it”)

Patient is a machine (“We need to ream out your plumbing”)

War metaphor

Disease is the enemy (“I treat all my patients aggressively”)

Physician is a warrior captain (“She’s a good fighter”)

Patient is a battleground (“The war on cancer”)

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Dr. Coulehan believes that contemporary medicine has now largely abandoned the parental (or paternalistic) metaphor, perhaps the most prevalent way of thinking about the patient-physician relationship in the good old days.

But try breaking that news to the Emergency Department physician who misdiagnosed me despite my textbook heart attack symptoms in 2008, and – just as alarming! – the ER nurse who returned to my bedside and sternly warned me after the doc had left my cubicle:

“You’ll have to stop questioning the doctor. He is a very good doctor and he does not like to be questioned.”

That paternalistic tone is pretty darned close to my own parents’ simple yet effective conversation stopper when I was a small child:

“Because I said so, that’s why!”

By the way, the question that initiated the nurse’s scolding? I’d had the temerity to ask the Emergency physician this understandable yet apparently unacceptable question while in mid-heart attack:

He explains, however, that the relative demise of paternalism in medicine has been accompanied by the rapid advance of those engineering and war metaphors, both of which are particularly prone to objectifying and dehumanizing the patient. He adds:

“Each sheds some light on the patient-physician relationship, but also casts a shadow. While capturing one characteristic of illness or healing, each one downplays or ignores certain other features.

“There are also other, more humane, metaphors for medicine; for example, physician-as-teacher, or physician-as-reader or editor.

“Obviously, we need many such images to capture the truth, but we must understand that none are exclusive, and some are more useful in healing than others.”

To me, the most cringe-worthy aspect of using such unhelpful metaphors (particularly combat comparisons) to describe patients and/or their conditions is the implication that those who “lose the battle” against their diagnoses somehow just haven’t fought as bravely as those who win that battle.

This is both hurtful and ignorant – and especially rampant when describing those with cancer. As retired cancer researcher Dr. Michael Wosnickobserved in his HealthyDebate essay:

“For those who ultimately die from a cancer, the idea that they have ‘lost’ a battle implies to me that if they had just done SOMETHING else differently, then maybe they might have ‘won’. The use of the word ‘lose’ is like a zero-sum game to me: if someone or something ‘loses’, then that means that someone or something else ‘wins’. You can’t have a loser if you don’t have a winner.

“Why do so many deaths from cancer get reported as ‘after a long struggle/battle, so-and-so lost his/her battle with cancer’? It’s not quite ‘blaming the victim’, but it does have ring of placing the ultimate responsibility for having died in the hands of the deceased.”

I agree with breast cancer blogger Nancy Stordahl at Nancy’s Point who poses this blunt question:

“Why not just ditch the winner/loser messaging altogether?”

“Why not just say, ‘ _____ died from breast cancer, lung cancer, heart disease, injuries sustained in an accident’, or whatever the cause was? And yes, even when talking about suicide, I would say it’s okay to come out and state, ‘ _____died of suicide’, or self-inflicted wounds, or whatever a family feels most comfortable with. Being forthright might eventually help reduce the stigma that suicide so often brings to families.

“I find it fascinating that we use and reuse some words and phrases over and over, yet at the same time we work really hard at avoiding other words. We go to great lengths to avoid using the ‘d’ words: death, die, dying, dead.

“Maybe we shouldn’t work so hard at avoiding them. Maybe just stating the simple, clear and honest truth would be better.”

When I worked in hospice palliative care, it was widely observed among my colleagues that the oncologists who had been treating our patients before they were referred for end-of-life care were also often reluctant to use the ‘d’ word with their cancer patients and their families – even those patients for whom continuing curative treatment was futile, and who quite clearly qualified for end-of-life care. No wonder so many of their patients felt like they were “losing the battle” when they decided to reject yet another round of aggressive treatment – thus losing their doctor’s battle to avoid a patient’s death.

Heroic combat metaphors are also damaging for bigger reasons. As I wrote here about the trendy pop science concept known as Post-Traumatic Growth (what doesn’t kill you makes you stronger, blahblahblah):

“My concern with this Post-Traumatic Growth expectation for patients is that not only are we supposed to manage a serious health crisis, but we’d better do this recuperation thing correctly so that we can emerge triumphantly at the other end with heroic results.”.

So far, very little since my own heart attack and subsequent diagnosis of inoperable coronary microvascular disease (MVD) has felt to me like much of a “fight”. It’s not a particularly heroic response against a chronic and progressive illness – unless you count getting out of bed in the morning, or taking a fistful of daily cardiac meds, or showing up for hospital, lab or doctors’ appointments, or putting one foot in front of the other. MVD is a uniquely painful and debilitating condition, but I’d never describe my response to it as any kind of “battle”.

NOTE FROM CAROLYN: I wrote much more about how we talk and think about our diagnoses in my book “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (and use their code HTWN to save 20% off the list price).

Not only do I abhor the military metaphors, I also HATE the expectation that this illness will make me a better person – as if I needed a life-threatening illness in order to become a better (tolerable?) member of society. AND I will endure it with grace, humor and compassion for everyone around me who has to live with my illness.

Finally – to me, it’s definitely not a ‘journey.’ At most, it’s a slog – a forced march that no one in their right mind would willingly undertake.

Great article, as always. I have mixed feelings on the whole “combat metaphor” issue, though — perhaps because I use it all the time on myself.

On the one hand, I can definitely understand the negative impact of the “losing” aspect of the metaphor. For a long time after my surgery, I felt extremely frustrated by any perceived setback in my recovery — not just because I was a bit jumpy and worried about something going wrong enough to require a second surgery, but because it felt like I had failed myself somehow. One day when I felt particularly upset I just broke down crying and started babbling something like, “I was doing SO well,” with the unspoken implication that, because I was now experiencing a (minor) issue with my recovery, I was no longer doing well. I was failing. It’s a horrible feeling, and I would never wish it on anyone else.

On the other hand, I tend to motivate myself to rise above my frustrations and worries by envisioning myself as some sort of hero — not that I’m saving the world or anything, but in the sense that I am (trying to be) the hero of my own life story by conquering my fears and any health setbacks that come my way the same way a knight slays a dragon — with courage, cleverness, and strength of will (and, ideally, physical prowess as well). Those little, everyday things that you mentioned, like getting up out of bed and actually doing something productive with your day even when you don’t feel like it — on very bad days, the combat metaphor is the most convincing argument I can present myself with in order to get such things done.

This all may sound a little childish, but it’s my go-to thought process when it comes to my health-related issues. The negative aspect does make me feel like there probably is (or at least should be) a better, more positive alternative for me, but I’m just not sure what it would be.

I loved reading your comment, Kim! I can sure relate to that “I was doing SO well!” scenario, especially in my very early days post-heart attack; one day in a fit of pique, for example, I marched around my apartment gathering up all the get-well cards and bouquets of flowers – and trashed the whole lot of them. I was sick of feeling sick and didn’t want all these reminders that some kind of sick person was living here. (It didn’t work, of course – I still felt awful…) That experience however served to confirm my suspicion that I was somehow doing this whole recovery thing “wrong”. I was “losing” this “battle” because I was obviously so weak and wimpy. Not good for my sense of self-compassion… 😉

Oh man. XD I did something similar with all the pamphlets my doctors had given me over the weeks leading up to surgery. I threw several away and tossed the rest into the bottom of a drawer — out of sight, out of mind, right? Except of course, it didn’t work for me either — which only made me more frustrated. Sigh.

I guess we’re all our own worst critics, even when it comes to our health. I’m working on it, though! 🙂

I missed this in 2013, so I am grateful you reposted. The perspective is one I can see back-firing. I am sure I have been prone to use the word fight or battle or survive. I think in a less understood condition such as MVD, it gave a larger purpose or action to me, especially in the beginning when less was even remotely malleable in the acknowledgement of it, let alone in my treatment.

Yet, this brings up a point … What about the flip side of this? What if it makes a patient feel as if they are failing? So easy to feel that way in a condition that morphs as it goes. Always a new ‘war’ as it were. Although I have come to see a much larger picture and understand acceptance is not defeat, there were times it felt like a curse. I perhaps gave it more power in the beginning than it deserved. I was, after all, still me. Not ‘it.’ But the less understood is scarier and we choose ways to cope. And it certainly often felt like- it is what it is. Then on another day? Beyond difficult to wrap around as a new symptom unveils itself. Chronic and debilitating can shrink a spirit and perhaps these names are meant to fake it til we make it. In the end we need more substance than that.

I think I know, through this, I have found myself a hopeful realist… I prefer the honesty of it. I don’t want it sugar coated! I also still find it useful to name what I work against the progressions of, in a recognizable personal way. The Beast.

I heard other MVD patients say this in the beginning and it made sense. Something mythical. Something otherworldly. It felt that way often. And I see I name it that, less and less as time goes and as I know more or experience more. Yet, I’m visual, and to me? I use that. I shrink that looming misunderstood figure with my knowledge, care and tame it and make it something to conquer. Something to move past and around or through as needed. The more I got to know it… the less scary was this beast, but I made a friend of the enemy so-to-speak.

I can see it can make our efforts at times less attainable or seem so out of reach or question our ‘fighting’ skills. Our health is most deserving of the truth and should not be completely mystified or marginalized. If we and our partners in health embrace the physical truths and work for different outcomes, it becomes our way of life to better and not some tiring fight but living through it. With it. Beyond it.

Thanks for this perspective to spur thought on being more specific.
Annette❤️✨

Hello Annette and thank you so much for sharing your astute perspective. Beautifully put. And “Chronic and debilitating can shrink a spirit” – amen to that!

Like most people living with chronic illness, I’m also thinking that the freshly-diagnosed are very, very different than those of us who already have several years experience taming “The Beast”. I once observed to my pain specialist, for example, that on a bad day, I have the kind of pain that would likely send the average person rushing straight to the E.R! This is especially relevant to chest pain (arguably a more terrifying kind of distress than a migraine or arthritis or back pain sufferer might experience). This reaction might also be similar to that “making a friend of the enemy” you poetically describe…

H Carolyn,
I am so weary of the war metaphors. They are mostly unhelpful, potentially hurtful and oftentimes harmful.

And I will ask again, why can’t we just say so and so died from cancer, heart disease or whatever it was? Clarity and honesty are always better, even when speaking about death. Like you, I also have little tolerance for the expectation that those dealing with serious illness should morph into a new and improved version of their former selves.

Sounds like one more attempt to frame serious illness as a gift in my view. I abhor that idea. And thank you very much for the mention.

I wonder whether gender dynamics play a role in this interesting article. Many males are socialized in sports, movies, books, and games in languages of war, battle, and struggle. As physicians they may see diagnostics and treatment much like a puzzle that needs solving so long as the patient is strong enough to hold on. I would definitely be interested to learn more about those other modalities.

I would be curious to know the gender ratios in particular medical disciplines. In my own profession, there is a sharp decline of female practitioners after 5 years so war metaphors remain quite pervasive. They remain pervasive despite every male presently practicing having no idea what war actually looks like and very few actively engaging in “battles” on a consistent basis.

Hi Dana – what an interesting issue you raise here! Historically, medicine, like law, has indeed been a male-dominated profession. This gender gap in medical specialties is a particular interest of mine too, ever since I learned at Mayo Clinic that only 7% of all cardiologists were female.

Things seem to be changing, however: in 2007, for example, 84% of ophthalmologists in practice were male. But now, 42% of those in their first five years of practice are women. In 2012, The New England Journal of Medicine reported that in medical residencies and fellowships, women outnumbered men in pediatrics, family medicine, and obstetrics-gynecology, and comprised nearly half of internists. But women remain highly under-represented in radiology and urology, and are still a distinctly small minority in many of the other surgical specialties. We know that about 30% of surgeons are women (unless you’re in neurosurgery – 10%, or worse, cardiothoracic surgery – just 5%).

So if combat/war/winning-losing metaphors are indeed representative of male-driven occupations, we may have a few more years to wait before workplace cultures actually begin to change.

I love Holly’s comment (below): yes, how about Doctor as Partner? That’s how I regard my primary care physician, who is thankfully able to see that role for himself. It acknowledges that we’re both grownups, and that, ultimately, it’s my life and my decisions that count.

I hate the battle metaphor. None of us wants to die before our time, but death is everyone’s last act, and we do ourselves a disservice by not being able to talk about it and thus prepare for it if we can.

Hello Kathi and thanks for this. You are fortunate to have a true partnership relationship with your doc. I’d imagine it’s also equally rewarding for him as well to work with an informed patient who is so engaged in her own health!

What I’m not reading here is Doctor as PARTNER. Only when doctors regard us as EQUALS will we really start to get better. When they stop dismissing symptoms because their training says those don’t count, or belong to another specialty, or they’re unusual. When they stop dissing our hours of research, our needs and concerns, our different physiologies – only then will we have a chance to become as healthy as our genetics allow. Yeah, I’m pissed about the way I’ve been treated in my health journey, almost brought to death by “expert” doctors who wouldn’t listen.

Hi Carolyn! I heard all three on my journey but the good doctors were teachers and philosophers!

What is so very interesting is that my wellness is ALSO described as a battle to be WON. Just yesterday I was talking to a dear friend who had a valve replaced during my time of illness, and I said “I am flat out tired of battling!!If I don’t come back to someone else’s memory of what I was, somehow that makes me a loser!” – I should be battling harder!

He totally got it because he still deals with fatigue even these many years on. He calls it “the chronic illness of open heart surgery” and he’s a Doctor! His comment was, “no one tells you how it really may be, so it is a character flaw if you aren’t as perky or clever as they recall!”

Thanks for bringing up this important point, JG: you not only have to ‘battle’ to survive the initial diagnosis and treatment, then you must ‘battle’ to bounce back to your perfectly normal self to the satisfaction of others (or risk, as your friend correctly identifies it, revealing some kind of character flaw!)

Carolyn,
You (as you are wont to do) are spot on here, as are many of the comments.

JetGirl brings up an excellent point: too often, others equate a treatment (e.g. an operation or medication) as a cure. The unspoken question is: “But I thought you got fixed?” — as if the intervention was a massive eraser removing all difficulty, all vestiges of illness and/or suffering.

I know I’m preaching to the choir, but ill health changes us, and the world around us wants certainty, not loose ends and untidy changing, and/or lingering conditions. Plus, we’ve deified medicine and pharma as magic cures, maybe watched too many medical dramas on TV, where smiles of gratitude before the last fade out hide the reality of recuperation, symptom relapse, adhesions, infections, and the lot.

(The surprise at the illnesses and chronic health conditions following the “successful” cases of Ebola recovery is another example: “But they beat Ebola!” goes the cry, as if massive post-infection harms just couldn’t be a result of that–or that we even know what Ebola does, long term, to those who survive its kiss.)

Thank you for this, Angela. I particularly appreciated that Ebola reference. It’s understandable (given how heroic the desperate medical effort was to contain/treat this deadly virus) that “saving” a patient was considered the only goal at the time. Real life back at home was simply not as important – much like it is here when patients are discharged from hospital. (For example, this post on shocking research suggesting 91% of those with chronic illness diagnoses are discharged with no written discharge plan for ongoing care!)

Holy hot Moses! And yet we wonder why the readmission rates are so high? Not that it’s the only factor of course, but to miss the opportunity to trim those numbers with such low hanging fruit as a written discharge plan. Egads.

UPDATE

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